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Nevertheless, most OECD countries show income-related inequities in the use of various health care services (Devaux and de Looper, 2012). Typically, lower-income people are less likely to visit doctors, especially specialists. Moreover, the proportion of unmet care needs is consistently higher in low-income groups than in high-income groups in OECD countries, with the reason mostly being reported as down to financial barriers.

Similarly, differences in life expectancy between the high and low educated at age 30 vary in the OECD area from

2.5 years among women in Slovenia to 17 years among men in Estonia.

Recently, some emerging market economies (China, India, Indonesia, South Africa) have committed themselves to providing UHC for their populations. Some of the key lessons based on OECD country experiences

and on-going OECD work with emerging economies to support them in progressing towards UHC, are as follows:

 It is more equitable (and more practical) to have full financial protection for a few of the most important and high-value-added services (e.g., vaccination, minor surgeries and care in the community) for everyone, and then to expand the range of health goods and services over time.

 Paying doctors and hospitals in the right way is more important than the decision about whether to have tax-based, social insurance or private finance for the system.

 Sequencing is important. Primary care and preventive interventions offer more health for the money.

 Using the private sector is often desirable where health care supply is scarce. In an environment of poor supply of health care, any possible source of health service provision should be considered.

Extending health coverage to more people and promoting equal access to healthcare by reducing barriers, especially financial costs, to seeking care are the main means through which health policies can promote Inclusive Growth. Prevention policies can be especially cost-effective ways to improve population health and reduce health inequality, and to achieve broader social welfare. Policies designed to tackle key behavioural risk factors for health, such as tobacco and alcohol use, unhealthy diets, physical inactivity, obesity, as well as chronic diseases such as diabetes, cardiovascular disease, cancer, chronic respiratory diseases, liver disease and mental health conditions, have the potential to increase employment and productivity, and to reduce social disparities in health.

These policy interventions, which are more cost effective than treating diseases when they emerge, include health education and promotion strategies; fiscal measures that increase the price of unhealthy food or reduce the cost of healthy foods; regulatory measures that inform on nutritional food content or restrict the marketing of unhealthy foods to children; and individual approaches such as physician and dietician counselling for high-risk people. For low- and middle-income countries, the OECD estimated that a package of prevention measures implemented in Brazil, China, India, Russia and South Africa would deliver substantial health gains, with a very favourable cost-effectiveness profile (Cecchini et al., 2010).

Source: Cecchini, M. et al. (2010). "Tackling of unhealthy diets, physical inactivity, and obesity: health effects and costeffectiveness." The Lancet, Vol. 376, No. 9754, pp. 1775-84; and Devaux, M. and M. de Looper (2012), “Income-related inequalities in health service utilisation in 19 OECD Countries, 2008-2009”, OECD Health Working Papers, No. 58, OECD Publishing, Paris.

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Note: Unmet health care needs are defined as people who report that they did not visit a doctor when they had a medical problem, did not get recommended care, or did not fill prescription/skipped dose because of cost in the past year.

Source: Commonwealth Fund (2013), “2013 Commonwealth Fund International Health Policy Survey There is a link between labour market and health status, resulting in a vicious circle of inequality in income and health outcomes. Despite significant efforts to provide universal basic health care, in many countries entitlements often depend on the labour market status of individuals, putting informal-sector workers at a disadvantage. In East Asian countries, for example, informal workers are often left without any type of health insurance. Considerable progress has been made in many countries in Latin America, but the region still lags behind OECD standards in many areas, and health disparities continue to be strongly dependent on socio-economic status. For example, the proportion of stunted children under 5 years of age is 45% in Peru’s poorest quintile, compared to 5% in the richest, and 23% in Brazil compared to 2% in the richest quintile (Althabe et al., 2007). Many countries also confront the issue of the “missing middle”: in Viet Nam, for instance, 64% of the total population was covered by health insurance in 2011, including 75% of the salaried workers and 92% of the poorest. However, only 25% of the ‘near-poor’ population, those who recently moved above the poverty line, were covered (Castel, 2014). The quality of care also correlates strongly with income, in part because of out-of-pocket expenditures and the cost of more comprehensive insurance packages, which puts the poor at a disadvantage.

1.5. The environment-inequality nexus: who is at a disadvantage?

Impact of environmental conditions on health Environmental conditions have improved overall, but remain worse for poorer individuals and children, affecting their health and earnings capacity. Worldwide, around one-quarter of diseases and overall deaths are due to poor environmental conditions (Prüss-Üstün and Corvalán, 2006), such as air and water pollution, exposure to hazardous substances and noise (Figure 1.26).

While access to sanitation facilities is less of a challenge for OECD countries, much progress is needed in developing countries, where 2.6 billion people still do not have improved sanitation, and 884 million people do not have access to improved sources of drinking water (WHO and UNICEF, 2010). Furthermore, even access to an “improved” water source does not necessarily mean access to “safe” water that is fit for human consumption. Indeed, half of Africa’s hospital beds are filled with people suffering from a water-related disease (OECD, 2012b). There are also indirect effects from climate change, transformations in the water cycles, biodiversity loss and natural disasters that affect the health of ecosystems and damage personal property and livelihoods. Environmental pollution leads to lost worker productivity due to illness and to increased costs of health care. The health effects on children, who are particularly vulnerable, could affect future labour productivity. For example, adults may acquire chronic respiratory illnesses after childhood exposure to air pollution.

Figure 1.26.

Projections of premature deaths from selected environmental risks in 2010, 2030 and 2050

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0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 Note: Child mortality only.

Source: OECD (2012d), OECD Environmental Outlook to 2050, OECD Publishing, Paris; output from IMAGE.

Despite improvements, air pollution remains at dangerous levels. In the last two decades, concentrations of airborne particulate matter in OECD and emerging countries have dropped significantly, but global levels are still about double the WHO annual limits of 20 micrograms for PM10. Air quality has improved with respect to SO2.The share of people living in areas with healthdamaging levels of pollution is particularly high in China, India, Indonesia and Chile (Figure 1.27). In the developing world, exposure to pollutants also comes from the indoor combustion of solid fuels in open fires or traditional stoves, and a lack of access to modern energy sources, which increases the risk of mortality among young children and the risk of chronic pulmonary disease and lung cancer among adults (WHO, 2013). The global number of premature deaths linked to outdoor air pollution is expected to rise from about 1.8 million today to around 4.4 million in 2050 due to exposure to both ozone and particulate matter (PM) (OECD 2012d).

Figure 1.27.

Population exposed to air pollution by small particulates (PM10) decreased in OECD and BRIICS countries over 1990-2009 but levels remain above WHO thresholds in several countries

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Challenge of access to water supply and sanitation Access to basic environmental services remains a major issue in emerging economies and developing countries (Figure 1.28). While access to sanitation facilities is less of a challenge for OECD countries, much progress is needed to help emerging countries such as India, Indonesia and China (Figure 1.29). Poor water supply and hygiene practices lead to 1.9 million deaths every year from diarrheal diseases, 90% of whom are children under the age of five.16 Despite strong calls for action at the international level, the Joint Monitoring Program, led by the World Health Organisation (WHO) and UNICEF, found that 2.6 billion people still do not use improved sanitation, whilst 884 million people do not use improved sources of drinking water (WHO and UNICEF, 2010).

Furthermore, even access to an “improved” water source does not necessarily mean access to “safe” water that is fit for human consumption.

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Note: Emerging economies include Brazil, China, India, Indonesia and South Africa. Developing and other economies include all other countries.

Source: OECD (2012d), OECD Environmental Outlook to 2050, OECD Publishing, Paris); output from IMAGE.

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Note: Emerging economies include Brazil, China, India, Indonesia and South Africa. Developing and other economies include all other countries.

Source: OECD (2012d), OECD Environmental Outlook to 2050, OECD Publishing, Paris); output from IMAGE.

Who suffers the most?

The environmental burden of disease (EBD), a measure of the environmental burden on society, shows high levels of environmental deterioration particularly in the emerging market economies.17 While the EBD ranges between 13% and 20% in many OECD countries, it reaches higher levels in Eastern Europe, Korea and Turkey, where up to one-third of the disease burden could be prevented through better environmental conditions (e.g. curbing air pollution and providing safe water and sanitation). According to the WHO, 24% of the total burden of disease at the world level, or 13 million premature deaths, could be prevented through environmental improvements (Prüss-Üstün and Corvalán, 2006). Also, the EDB most strongly affects the poorest, the youngest and the oldest populations. In developing countries, the poor typically live in less healthy areas and are more vulnerable to indoor air pollution from solid fuel use, and the communicable diseases associated with poor water and sanitation facilities (e.g. diarrhoea and malaria). In advanced economies, environmental problems tend to affect low-income families and communities as well. Short-term effects of high PM10 concentration appear to be largely restricted to people of low socio-economic status, due to a combination of greater susceptibility and higher exposure (Gwynn and Thurston, 2001). The very young and the very old are more at risk than the remainder of the population to air pollution and other environmental hazards (Pope and Dockery, 1992) (Schwartz, 1994) (Box 1.5).

Box 1.5. The effects of air pollution on children's health

It has been estimated that 43% of the global environmental burden of disease falls on children under five, and that 80% of the burden of disease for infants and young children has an environmental origin. According to the WHO Task Force on the Protection of Children’s Environmental Health, respiratory infections account for 20% of mortality in children under the age of five. Many OECD countries also report asthma epidemics that are aggravated by air pollution. The United States, for example, has approximately 4.8 million school-age children with asthma.

Much of the existing literature regarding environmental effects on human health has focused on adults. Despite a large number of actions undertaken in OECD countries to protect children’s health from environmental degradation, most existing legislation does not take into account children’s special vulnerability to environmental risks. Early epidemiological evidence suggests that in many cases, children do not have the capacity to metabolise and detoxify toxic compounds the way adults can. During development, children require a high rate of energy consumption, and large amounts of food, air and water intake expose them to more pollution than adults (e.g. when children are exercising during sport events, they may take in 20% to 50% more air, and thus air pollution, than adults in comparable activities). Different behavioural patterns in children may also play a role in their particular vulnerability to environmental health effects. Children spend more time outside than adults, and are often outdoors during times when air pollution is at its highest. Furthermore, children have more time to develop diseases that take years to occur, such as cancer, cardiovascular and neurodegenerative disease. Moreover, children are more susceptible to sustained chemical exposure. When a product appears on the market, children may remain exposed to its chemicals throughout their lives, while adults necessarily live with the chemical exposure for a shorter period.

Sources: OECD (2006b), Economic Valuation of Environmental Health Risks to Children, OECD Publishing, Paris and OECD (2008c), OECD Environmental Outlook to 2030, OECD Publishing, Paris.

Pollution is worse in urban areas in all countries. In many urban regions in Europe, a large share of population is exposed to elevated values of particulate matter above an annual average concentration of 20 μg/m3 in 2010 (EEA, 2013), levels that present a high health risk. Ozone pollution affects urban dwellers in OECD countries, but urban dwellers in developing countries also face particular environmental challenges. The share of city dwellers without access to treated water is high and rising in sub-Saharan Africa, where the Millennium Development Goal for improved water supply is unlikely to be met. Fast urbanisation in Africa and Asia has led to higher concentrations of air pollution (Box 1.6). All emerging countries except Brazil and South Africa have particulate matter levels well above the OECD average. Only 2% of the global urban population are currently living below the WHO Air Quality Guideline of 20 μg/m3, while about 70% of the urban population in the BRIICS and non-OECD member countries are exposed to concentrations above the highest interim standard (above 70 μg/m3). The OECD Environmental Outlook to 2050 projects OECD countries as a group to have one of the highest ozone-related mortality rates in terms of number of deaths per million inhabitants – second only after India and higher than China and other emerging economies – due to the much greater ageing of the population (Figure 1.30) (OECD, 2012d).

Figure 1.30.

Premature deaths in urban areas from exposure to particulate matter (PM10) are projected to rise substantially in emerging economies by 2050

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Note: For urban areas with populations over 100 000. Emerging market economies include Brazil, China, India, Indonesia and South Africa. Developing and other economies include all other countries.

Source: OECD (2012d), OECD Environmental Outlook to 2050; output from IMAGE.

Box 1.6. Drivers of urban pollution The year 2008 marked the first time in which more than half of the world’s population lived in towns and cities.

By 2030, it is estimated that this number will swell to almost 5 billion people (UNFPA). Such rapid urbanisation presents challenges that may threaten the environment and quality of life. Outdoor pollution is one of the main

problems facing growing cities, and comes from a range of anthropogenic sources:

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